GW1-2023-02107_Well Construction - GW1_20230303

VaLL.CONSTRUCTION RECORD(OM 11 ForIntemal Use Only: -
1.Well Contractor Infor
m
ation:
14.WATERZONES
1VelI Contractor Name FROM TO i DESCRIPTION
NCNVellContractorCe�cationNumber r�� 73 f� I
fl If.ODTIM CASING for mTIM-= ells OR LINER if ]Icabie
Vy r j f,r J `��l FRObI To DIAMETER THICI{NESS i4L�TERiAL
t ft ft. ia.
CompanyName�
16.IN'NEIt.CASWC ORTQSING thermaldosed-loo )
2.Well Constractiou Permit& 3 F,306'7• >N7tolvl TQI DrAMEYM I TM(!kWESs I MA-mmAr,
Listallapplicable tveH construclionpenairs rIA UIG Count';Stag Variance.eta) • ft• in-
3.Vlbell Use(chedrwefruse}: it• in•
Water Supply Well: 17.SCREEN
FROM I TO I DLAMETER I SLOTSIZE I TWCK'ivESS I MATED
•RgticuItural E3 l/Pu unicipablic ft. fL is
Geothermal(Heating/Cooling Supply) ORaddentlai-Water Supply(single)
. •Industrial/Commercial DResidential Water Supply(sllated)
_ t8.GROUTIIrlgatiOn. FROM TQ i4UT_M L EMPLACENIEN UMOD&ADI
Non--Water Supply Well: M it•
OMonitoringRecovery rt. ft. ' -
Inlectfon Well: ft. ft.
Aquifer Recharge Groundwater Remediation mg.SANDIGRAVEL PACK'(if a "Iicable
r5torageandRecovery 08alinityRanier FROM TO MATERIAL I EMPLACE1tiENTMETHOL
Aquifer Test OStormwaterDrainage it.
F.xpeomental Technology DSubsidence Control fL ft.
Geothermal(Closed Loop) DTracw 20.DRII.LINGLOG(attach additional sheetsifnecessa •
_Geothermal(fieatin FRo ' DESCRIPTION(wlor.batdoess,snE/mcht size
gJCooIimgRetnm} _ Other(explaiaunderlr2lRemarks} � COO
it. C �k
4.DateWell(s)Completed: '-E/ -Z� WeIIID# ft• it
SaWell Lor�ati�o•,,R:
ft. ft.
Rick�iC k C51i ft. ft. _
Eactlity/OwuccNamc Faci(ityIA#�fappficable) % ft �� -- _ jf z 3
Z �� Moar�l ,w13�.S� y��le.l�/C..2�G72
Physical Addtrss,Cut,,and Zip I ' ft fi: MAN '. ZRJ
0 f o go 12GGq_ Z1.12LB�fARIfS
County . PatcelIdentificadon-No..(PIN)
5b.Latitude andlongitude in degreeslminutes/seconds or decimal degrees:
(ifwcUffe , latllougissuffcient} Z2,Certifieatio
3C, �r E N�,3 3'��� W f-ZU-23
6.Is(are)the well(s)dermanent or OTemporary Signauue ofCettified Well Date
By signing this form,l hereby certify that the wells)ivas(were)Contracted in acc
7.Is this a repair to an existing well: eY. or nNo waft 1SANCAC 02C-0100 or ISANCAC 02C.0200 Well Construction Standardr or.
If this is a t enatr,fdt out knatm well constrwam ttformntion and explain the no tare ofthe cope afd&record has bemprovlded to the yvell owner-
repair:tnder-21 remarks section or on die back oftWorm 23.Site diagram or additionai well detafls:
3.For GeoprobeWPT or Closed-Loop Geothermal Wells having the same you may use the back of this gage to provide additional well site details
construction,only I rC W"-1 is needed. Indicate TOTAL NUMBER of wells construction details.You may also attack additional pages if necessary..
drilled: 5MN11TTALINSTRUCTIONS
9-Total well depth below land surface: ( ) Ma,For All Wells; Submit this form within 30 days of completion
Farmultiple welts Gst all depths sfdifferew(example-3Qa 200'and 2(WO) construction to the following:
10.Stefic water level below top of casing: 2�G` (ft.) Division of Water Resources,Information Processing Unit,
'KIWer level is above casing,ttse 1617 Mail Service Center,Raleigh,NC 276994617
�
11.Borehole diameter: !7 VT (in.) %24b.ForIniection Wells: In addition to sending the form-to the address
above,also submit one copy of this form within 30 days of completion
12.Well.constrac#ou method:.4I� constmatio*W die following;
CI.-augur-tat',sable,d metpusk etc.)
Division of Water Resources,IlndergroundNection Control Progr
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I.� Method of test: Tula For Water Supply&Injection'Wells: In addition to sending the:
l 1 1 p z the address(es) above, also submit one copy of this form within 30 t
13b.Disinfeetion type: I-14"n-f Amount: completion of well construction to the counbr health department of the
where constructed.